Inhaled: Beclometasone (Clenil®, Qvar®, Kelhale®, Soprobec®), Budesonide (Pulmicort®), Ciclesonide (Alvesco®), Fluticasone (Flixotide®), Mometasone (Asmanex®) Inhaled combination products include AirFluSal®, Atectura®, DuoResp®, Enerzair®, Flutiform®, Fobumix®, Fostair®, Luforbec®, Relvar®, Sereflo®, Seretide®, Sirdupla®, Symbicort®, Trelegy®, Trimbow®, Trixeo® although this list is not exhaustive Intranasal: Beclometasone (Beconase®, Betnesol®), Budesonide (Benacort®, Rhinocort®), Fluticasone (Avamys®, Flixonase®), Mometasone (Nasonex®), Trimacinolone (Nasacort®) Intranasal combination products include Betnesol N®, Dymista® [For patients taking oral corticosteroids - see Corticosteroids (Systemic) monograph] |
Issues for Surgery |
For suppression of inflammatory and allergic disorders (including asthma, chronic obstructive pulmonary disease [COPD], allergic rhinitis) – increased risk of disease relapse if omitted. Potential increased risk of acute adrenal insufficiency (e.g. severe hypotension, tiredness and weakness, confusion, psychosis, tachycardia) if omitted – see Further Information. |
Advice in the Perioperative period |
Elective and Emergency Surgery There are numerous inhaled and intranasal preparations which contain corticosteroids, either as single agents or in combination products with antimuscarinics and / or long-acting beta2 adrenoceptor agonists – all of these can be continued pre-operatively. Check active ingredients of currently available preparations in the British National Formulary and see also Antimuscarinics (Inhaled and Nebulised) monograph and Long-acting Beta2 Adrenoceptor Agonist (Oral and Inhaled) monograph if applicable. Advise patients who do not use their inhaled corticosteroids as prescribed to use regularly to optimise disease control prior to anaesthesia. Advise patients taking regular inhaled or intranasal corticosteroids that their corticosteroid medication should not be abruptly stopped1,2. Confirm the brand, device and strength with the patient (for beclometasone see Further Information). Perioperative Considerations For patients taking systemic corticosteroids in addition to inhaled / intranasal corticosteroids see Corticosteroids (Systemic) monograph. Post-operative Advice If patients are unable to resume their usual inhaled corticosteroid medication post-operatively, supplementation with nebulised or systemic corticosteroids may be considered if clinically indicated, particularly if there are concerns regarding adrenal suppression – see Further Information. Intranasal preparations |
Interaction(s) with Common Anaesthetic Agents |
None anticipated with inhaled / intranasal use3,4,5,6; however, bear in mind the possibility of systemic absorption and thus the relevance of interactions listed in Corticosteroids (Systemic) monograph – see Further Information. |
Interaction(s) with other Common Medicines used in the Perioperative Period |
None anticipated with inhaled / intranasal use3,4,5,6; however, bear in mind the possibility of systemic absorption and thus the relevance of interactions listed in Corticosteroids (Systemic) monograph – see Further Information. |
Further Information |
Systemic Absorption Adrenal Suppression, Perioperative Stress and Corticosteroid Replacement The possibility of adrenal insufficiency should be considered in individuals taking inhaled or intranasal corticosteroids who fail to improve as anticipated post-operatively. Current evidence on the necessity of administering perioperative stress-dose steroids for patients with suspected secondary adrenal insufficiency is inadequate to either support or refute this practice1,2, however, if adrenal insufficiency is suspected, corticosteroid replacement appears to carry minimal risk compared with the risk of adrenal crisis1. For guidance on replacement, where clinically indicated, see Corticosteroids (Systemic) monograph. Prescribing Information
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References |
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